1
|
Kamceva M, Strickland J, Gatti J, Grimstad FW. Use of vaginoscopy following vaginoplasty in individuals with congenital adrenal hyperplasia. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00272-9. [PMID: 39187118 DOI: 10.1016/j.jpag.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 08/16/2024] [Indexed: 08/28/2024]
Abstract
STUDY OBJECTIVE To explore the use of exam under anesthesia with vaginoscopy (EUA-V) following vaginoplasty in patients with congenital adrenal hyperplasia (CAH). DESIGN Retrospective cohort METHODS: An IRB-approved retrospective chart review was performed of the post-surgical follow-up care of all patients diagnosed with classical CAH who sought care at a tertiary children's hospital from 2000-2017 and had undergone vaginoplasty at that institution. RESULTS Twenty-six patients met inclusion criteria. The median age at vaginoplasty was 1.25 years (IQR: 0.67, 9). Median post-surgical follow-up was 5.5 years (IQR: 1.5, 9). Twenty six EUA-Vs were performed, on 22 patients. Four were for complication assessment (rectovaginal fistula (1); urethrovaginal fistula (3)-on the same patient). The remaining 22 EUA-Vs, performed on 20 patients with two each undergoing two EUA-Vs, were planned for routine evaluation of vaginal patency. They were done a median of 0.67 years (IQR: 0.25, 2) following surgery and at a median of 6.67 years of age (IQR: 1.75, 12). Of these, five EUA-Vs identified stenosis in five patients (25%), a median of 0.91 years (IQR: 0.5, 7) after surgery, at a median age of 8.42 years (IQR: 2, 10.92). Of the four who did not undergo EUA-V, one had stenosis on clinical exam with ultrasound-verified hematocolpos. The remaining three were all prepubertal at last follow-up. CONCLUSION The majority of CAH patients following vaginoplasty underwent routine EUA-V, roughly a quarter of which detected stenosis. EUA-Vs may play a beneficial role in routine post-op care following vaginoplasty in patients with CAH.
Collapse
Affiliation(s)
- Marija Kamceva
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Julie Strickland
- Division of Gynecology, Department of Surgery, Childrens' Mercy Hospital, Kansas City, MO; Department of Obstetrics and Gynecology, University of Missouri Kansas City, Kansas City, MO
| | - John Gatti
- Department of Urology, Childrens' Mercy Hospital, Kansas City, MO; Department of Urology, University of Missouri Kansas City, Kansas City, MO
| | - Frances W Grimstad
- Division of Gynecology, Department of Surgery, Childrens' Mercy Hospital, Kansas City, MO; Department of Obstetrics and Gynecology, University of Missouri Kansas City, Kansas City, MO; Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.
| |
Collapse
|
2
|
Srinivas S, Morin JP, Bergus KC, Armon N, Griffin KL, Jayanthi V, Wood RJ, Dajusta DG, Fuchs ME. Following a strict renal protection protocol in cloacal malformations: A descriptive analysis. J Pediatr Urol 2024; 20:725.e1-725.e7. [PMID: 38964975 DOI: 10.1016/j.jpurol.2024.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/01/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND In children with cloacal malformations, renal dysfunction is a constant concern, with reported incidence as high as 50%. Multiple factors exist that may impair renal function. Our institution follows a strict renal protection protocol in this population. Incidence of renal dysfunction in these patients is unknown. OBJECTIVE We aimed to evaluate incidence of renal dysfunction while implementing this protocol in a cohort of children with cloacal malformation. STUDY DESIGN We reviewed a prospectively collected database of children with cloacal malformations managed at a single institution since implementation of a renal protection protocol. This involves regular laboratory evaluation, appropriate selection of total urogenital mobilization or urogenital separation, proactive imaging in patients with signs of impending renal dysfunction or urinary retention, and early catheterization teaching and implementation if necessary. Glomerular filtration rate (GFR) was calculated with the Schwartz formula and CKD grades assigned per standard definitions. Renal dysfunction was defined as CKD grade 3b or higher, need for renal replacement therapy (RRT) or transplantation. Descriptive statistics were computed. RESULTS A total of 105 children were managed under this protocol with a median follow-up of 4.2 years [IQR: 2.0-5.9]. Six children (5.7%) had renal dysfunction at most recent follow-up; of these children, only three (2.9%) progressed from normal renal function at initial evaluation to renal dysfunction (Table). No child with normal presenting renal function thus far has progressed to require dialysis or transplantation. DISCUSSION Previous literature estimated rates of renal dysfunction in cloaca patients as high as 50%; in contrast, we demonstrate a rate of progression to renal dysfunction of 2.9% in girls following a strict renal protection protocol. Most children who developed renal dysfunction had dysfunctional kidneys on presentation. This suggests that preservation of renal function may be possible in early childhood with a strict, multi-disciplinary renal protection protocol. CONCLUSION In our cohort of patients with cloacal malformations following a strict renal protection protocol, incidence of progressive renal dysfunction is low at 2.9%. Most who go on to renal dysfunction present with impaired renal function.
Collapse
Affiliation(s)
- Shruthi Srinivas
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jacqueline P Morin
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Katherine C Bergus
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Natalie Armon
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kristine L Griffin
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Venkata Jayanthi
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel G Dajusta
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Molly E Fuchs
- Department of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| |
Collapse
|
3
|
Arion K, Araoye I, Lo A, Beaudry P, McQuillan S. Revision of the VACTERL Acronym for the Screening of Gynecologic/Genitourinary Anomalies in Patients With Anorectal Malformations. J Pediatr Surg 2024:161638. [PMID: 39142957 DOI: 10.1016/j.jpedsurg.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 08/16/2024]
Affiliation(s)
- Kristina Arion
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada; Department of Pediatric and Adolescent Gynecology, Alberta Children's Hospital, Calgary, AB, Canada.
| | - Ibukunoluwa Araoye
- Department of Pediatric General Surgery, Alberta Children's Hospital, Calgary, AB, Canada
| | - Andrea Lo
- Department of Pediatric General Surgery, Alberta Children's Hospital, Calgary, AB, Canada; Section of Pediatric Surgery, Department of Surgery, University of Calgary, AB, Canada
| | - Paul Beaudry
- Department of Pediatric General Surgery, Alberta Children's Hospital, Calgary, AB, Canada; Section of Pediatric Surgery, Department of Surgery, University of Calgary, AB, Canada
| | - Sarah McQuillan
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada; Department of Pediatric and Adolescent Gynecology, Alberta Children's Hospital, Calgary, AB, Canada
| |
Collapse
|
4
|
Clain EC, Woodfield K, Hutchens KJ, Bischoff A, Alaniz VI. Obstructed Hemivagina and Renal Anomalies in Patients with and without Anorectal Malformations. J Pediatr Adolesc Gynecol 2024; 37:205-208. [PMID: 38122961 DOI: 10.1016/j.jpag.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
STUDY OBJECTIVE To compare the anatomic variation between patients with a diagnosis of an obstructed hemivagina with an anorectal malformation (ARM) and those without an ARM. METHODS This was a retrospective chart review conducted at a single tertiary children's hospital. Patients with an obstructed hemivagina seen from 2004 to 2019 were included. RESULTS We identified a total of 9 patients diagnosed with an obstructed hemivagina: 4 patients with a history of ARM and 5 patients without an ARM. Patients presented with obstructive symptoms between the ages of 11 and 20. Two-thirds of patients had a left-sided obstruction. All patients without an ARM had ipsilateral congenital anomalies of the kidney and urinary tract. Half the patients with a history of ARM had an ipsilateral renal anomaly, and the other half had a contralateral renal anomaly. CONCLUSION Obstructed hemivagina occurs in patients with a history of ARM. However, unlike patients with isolated obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), patients with an ARM and an obstructed hemivagina can present with associated renal anomalies on either the ipsilateral or contralateral side. In our small case series, patients with a history of ARM had high septa and required more complex surgical management due to the inability to access the septum vaginally. Knowledge of renal anatomy and ureteral path is important because a hysterectomy may be needed to relieve the obstruction in patients with ARMs. A larger case series is needed to better characterize the spectrum of complex anomalies in patients with ARMs.
Collapse
Affiliation(s)
- Elizabeth C Clain
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado.
| | - Kellie Woodfield
- Department of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Aurora, Colorado
| | - Kendra J Hutchens
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado
| | - Andrea Bischoff
- Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado
| | - Veronica I Alaniz
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado; Department of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Aurora, Colorado
| |
Collapse
|
5
|
Harris KT, Kong L, Vargas M, Hou V, Pyrzanowski JL, Desanto K, Wilcox DT, Wood D. Considerations and Outcomes for Adolescents and Young Adults With Cloacal Anomalies: A Scoping Review of Urologic, Colorectal, Gynecologic and Psychosocial Concerns. Urology 2024; 183:264-273. [PMID: 37839472 DOI: 10.1016/j.urology.2023.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/07/2023] [Accepted: 08/30/2023] [Indexed: 10/17/2023]
Abstract
The objective of this scoping review is to provide a summary of the current literature regarding adolescents and young adults with histories of cloacal anomalies. Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews were used. Data were categorized into four domains-urologic, colorectal, gynecologic/obstetric, and sexual/psychosocial. The current literature has poor study quality and mostly consists of retrospective studies of small cohorts with varying definitions of outcomes. Women with cloacal anomalies are at high risk for urologic dysfunction but can maintain kidney health and achieve social continence with medical and surgical management. Sexual function and adult healthcare transition are areas ripe for improved future research.
Collapse
Affiliation(s)
- Kelly T Harris
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO.
| | - Lily Kong
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Maria Vargas
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Vincent Hou
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Jennifer L Pyrzanowski
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Kristen Desanto
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Duncan T Wilcox
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Dan Wood
- Pediatric Urology Research Enterprise (PURE), Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO; Division of Urology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
6
|
Ahmad H, Knaus ME, Gasior AC, Jimenez AN, Spieth PT, Srinivas S, Stanek JR, Levitt MA, Wood RJ, Hewitt GD, McCracken KA. Sexual and Reproductive Health Outcomes in Females With Cloacal Malformations and Other Anorectal Malformations. J Pediatr Adolesc Gynecol 2023; 36:148-154. [PMID: 36522819 DOI: 10.1016/j.jpag.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/16/2022] [Accepted: 10/15/2022] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To improve our understanding of reproductive health and sexual function in women with cloacal malformations and other anorectal malformations (ARMs) METHODS: An observational cross-sectional survey was administered to individuals assigned female at birth aged 12 to 55 with ARMs and cloacal malformations cared for at our institution. Data included age of thelarche/menarche and questions on body image, gynecologic anatomy, sexual function, and pregnancy. RESULTS Twenty-one patients responded in the ARM group and 30 in the cloacal malformation group. There were no differences in median age of thelarche/menarche in patients with ARMs (11/12.5 years) compared with patients with cloacal malformation (11/12 years). Patients with ARMs were more likely to have native vaginal tissue than those with cloacal malformations (n = 18, 82% vs n = 12, 40%; P = .03). There were no differences between groups regarding concerns about dyspareunia and functionality of their vagina (P > .05). Forty-two percent of patients with cloacal malformations and 30% of patients with ARMs reported having been sexually active. Two patients with cloacal malformations and 2 with ARMs reported having been pregnant. Patients with cloacal malformations reported a lower quality of life score (80.4) compared with those with ARMs (87.0) (difference > 4.5). CONCLUSIONS Patients with a cloacal malformation were less likely to have native vaginal tissue and reported a lower quality of life than those with ARMs. Despite this, patients with a cloacal malformation had similar reproductive health and sexual function compared with patients with ARMs. Our results reinforce the need for comprehensive sexual and reproductive health care for all women with ARMs.
Collapse
Affiliation(s)
- Hira Ahmad
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Maria E Knaus
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Alessandra C Gasior
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Colorectal Surgery, The Ohio State University, Columbus, Ohio
| | - Alberta Negri Jimenez
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Paige T Spieth
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Shruthi Srinivas
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R Stanek
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio
| | - Marc A Levitt
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Geri D Hewitt
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio; Pediatric & Adolescent Gynecology & Obstetrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Kate A McCracken
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio; Pediatric & Adolescent Gynecology & Obstetrics, Nationwide Children's Hospital, Columbus, Ohio.
| |
Collapse
|
7
|
Lane VA, Lall A, Jaffray B. Single institution experience of cloacal malformation. J Pediatr Surg 2023; 58:270-274. [PMID: 36384941 DOI: 10.1016/j.jpedsurg.2022.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The aim of this study is to report on the outcomes of patients born with cloacal malformation, managed at a single institution more than the last 28 years. The focus of this study is the long term renal and colorectal outcomes. METHODS Patients were identified from the departmental database from 1994 to 2021. The medical records and operative notes were retrospectively reviewed. RESULTS Twenty-one patients fulfilled the inclusion criteria. Eleven long common channel (LCC) and ten short common channel (SCC) cloacae patients were identified. Median age at the time of primary reconstruction was 11 months in both groups. In the LCC group, seven (63.6%) patients underwent a Total Urogenital Mobilisation (TUM), and 4 (36.4%) required a vaginal replacement. 6/11 (54.5%) of patients required drainage of a hydrocolpos. In the SCC group, four patients required a TUM, two patients underwent mobilisation of the rectum and vagina alone, and three underwent rectal mobilisation alone. Two patients have required renal transplant for congenital renal dysplasia, and two have developed chronic renal failure associated with the sequalae of vesicoureteric reflux. Eleven (52.3%) of the patients manage their bowels with an antegrade continent enema (ACE), and two of the LCC cloaca are defunctioned with a colostomy. Clean intermittent catheterisation is performed by 12 (57%) of the patients, either per urethra or via a Mitrofanoff channel. CONCLUSION The urinary and faecal continence are the main challenges in the management of cloaca patients. Many require surgical intervention to achieve social continence. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Victoria A Lane
- Department of Paediatric Surgery, The Great North Children's Hospital, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK
| | - Anupam Lall
- Department of Paediatric Surgery, The Great North Children's Hospital, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK
| | - Bruce Jaffray
- Department of Paediatric Surgery, The Great North Children's Hospital, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK.
| |
Collapse
|
8
|
Taher HM, Fares A, Wishahy AM. Laparoscopic Resurrection of an Old Technique: A New Approach for Total Urogenital Separation and Rectal Pull-Through in Patients with Long Common Channel Cloacal Malformation. J Endourol 2022; 36:1177-1182. [PMID: 35152733 PMCID: PMC9422784 DOI: 10.1089/end.2021.0724] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Aims: Before the significance of urethral length was highlighted in patients with cloacal malformation, total urogenital mobilization using a posterior sagittal approach was recommended for common channel (CC) length <3 cm, those >3 cm it was followed by urogenital separation. However, many urologists are advocating that the urethral length rather than length of the CC should influence the choice of operation. It is also recommended that total urogenital mobilization should be avoided in patients with short urethral length as intraoperative decision to shift to urogenital separation will risk devascularization of the urethra, advocating total urogenital separation (TUS) from the start; the later technique was deemed difficult using open approach. We describe our experience with laparoscopic TUS and rectal pull-through in patients with cloacal malformation. Methods: Six patients were operated for a period of 3 years from December 2017 to July 2021; they underwent laparoscopic TUS and rectal pull-through. Preoperative investigations included cystoscopy, genitogram, and MRI pelvis and abdominal ultrasound. IRB approval has been obtained from research ethical committee at Cairo University. Results: Six female patients born with single perineal opening had colostomy at birth. Age during the second operation ranged from 1 to 4 years. Length of the CC ranged between 2 and 5 cm. Proximal urethral length ranged between 0.5 and 1.5 cm and vaginal depth >3 cm. Average operative time was 4.25 hours. Postoperative period was 1-5 days and uneventful. On the long-term follow-up. No patient developed urethrovaginal fistula and one patient developed vaginal stenosis. All patients had no urinary problems, dry over 4-hour interval, voiding spontaneously, and had normal kidney functions. Conclusions: Laparoscopic urogenital separation, as well as vaginal and rectal pull-through for cloacal malformation, is feasible in cloacal malformation providing anatomical repair.
Collapse
Affiliation(s)
| | - Ahmed Fares
- Department of Pediatric Surgery, El Fayoum University, El Fayoum, Egypt
| | | |
Collapse
|
9
|
Ellerkamp V, Rall KK, Schaefer J, Stefanescu D, Schoeller D, Brucker S, Fuchs J. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021; 18:1797-1806. [PMID: 37057496 DOI: 10.1016/j.jsxm.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/31/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary vaginal stenosis may occur after reconstruction of genital malformations in childhood or after failed vaginal aplasia repair in adults. AIM This study focusses on the results of the surgical treatment of these patients in our multidisciplinary transitional disorders/differences of sex development team of pediatric surgeons and gynecologists. METHODS A retrospective analysis was carried out on adult and female identified disorders/differences of sex development patients with vaginal stenoses treated between 2015 and 2018 in a single center with revision vaginoplasty. The underlying type of malformation, the number and surgical techniques of vaginoplasties in infancy, techniques of revision of the stenotic vagina, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. A review of literature with regard to recommended surgical techniques of revision vaginoplasties was accomplished. OUTCOMES To describe the surgical technique, the main outcome measures of this study are vaginal calipers after revision vaginoplasty as well as ability for sexual intercourse. RESULTS Thirteen patients presented with vaginal stenosis with a median age of 19 years (range 16-31). All patients had one or more different types of vaginoplasties in their medical history, with a median age at first vaginoplasty of 15 months (0-233). Underlying anatomical conditions were urogenital sinus (n = 8), vaginal agenesis (n = 2), persistent cloacae (n = 2), and cloacal exstrophy (n = 1). The main symptoms were disability of sexual intercourse in 13 patients due to stenotic vaginal tissue. The most frequently performed surgical technique was partial urogenital mobilization with a perineal or lateral flaps (n = 10), followed by bowel vaginoplasty (n = 2), in 1 patient a revision vaginoplasty failed due to special anatomical conditions. In a median follow-up of 11 months, all but one patient presented with physiological vaginal length and width, and normal sexual intercourse in those with a partnership. CLINICAL IMPLICATIONS Perineal flap with partial urogenital mobilization should be considered as a treatment of choice in severe cases of distal vaginal stenosis and after multiple failed former vaginoplasties, while bowel vaginoplasty should be reserved only for cases of complete cicatrization or high located stenosis of the vagina. STRENGTHS & LIMITATIONS The strength of this study is the detailed description of several cases while the retrospective character is a limitation. CONCLUSION In patients after feminizing genital repair, perineal flap with partial urogenital mobilization provides a normal anatomical outcome and allows unproblematic sexual intercourse. Ellerkamp V, Rall KK, Schaefer J, et al. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021;18:1797-1806.
Collapse
Affiliation(s)
- Verena Ellerkamp
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Tuebingen, Tuebingen, Germany.
| | - Kristin Katharina Rall
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Juergen Schaefer
- Department of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Diana Stefanescu
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Dorit Schoeller
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Sara Brucker
- Department of Gynecology and Obstetrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Joerg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Tuebingen, Tuebingen, Germany
| |
Collapse
|
10
|
Transition Care from Adolescence to Adulthood: A 10-Year Service Review of the Gynecological Implications for Young Women and Girls Born with Cloacal Anomalies. J Pediatr Adolesc Gynecol 2021; 34:412-414. [PMID: 33444778 DOI: 10.1016/j.jpag.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/27/2020] [Accepted: 01/01/2021] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To establish the gynecological and reproductive outcomes for girls born with a cloacal anomaly, seen in a pediatric specialist cloaca clinic. DESIGN Local approval was granted to conduct this review. Outcomes were retrospectively identified using healthcare records. PARTICIPANTS Girls with known cloacal anomaly, seen in the cloaca clinic between 2009 and 2019, who had attained menarche or received gynecological input. RESULTS Nine females met the inclusion criteria, who were 12-30 years old. The mean age of menarche was 12 years (SD = 1.29). Two developed obstructed menstruation, requiring surgical intervention. Vaginal stenosis affected all women. Three women underwent revision surgery, and 1 is awaiting surgery. None of the women have attempted a pregnancy, to our knowledge. CONCLUSION Cloacal anomaly is a rare complex condition. Female individuals with cloacal anomaly require multidisciplinary gynecology specialist care throughout adolescence and adulthood. Provision of a dedicated gynecological service could improve the quality of life of these women.
Collapse
|
11
|
Pregnancy Outcomes in 2 Women Born with Complex Anorectal Malformations: Challenges and Considerations. J Pediatr Adolesc Gynecol 2021; 34:424-426. [PMID: 33388445 DOI: 10.1016/j.jpag.2020.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Complex anorectal malformations (ARMs) are a group of rare congenital malformations involving numerous anomalies that require reconstruction and can affect sexuality, fertility, and pregnancy outcomes. Few cases of pregnancy in complex ARM patients have been reported. CASES We report on 2 patients with ARMs who delivered 3 term infants, all by cesarean section with successful collaboration between pediatric urologists and obstetricians. Both patients fully recovered with no long-term consequences after experiencing maternal morbidities including urinary infections, clitoral abscesses, vaginal lacerations, extensive adhesive disease, bladder injury, and maternal hemorrhage. SUMMARY AND CONCLUSION In managing pregnancies and deliveries in women with complex ARMs, coordination between obstetricians, pediatric urologists, and pediatric surgeons is crucial.
Collapse
|
12
|
Saxena R, Pathak M, Sinha A, Thummalapati JK. Single perineal opening with 'H-type' cecovesical fistula and blind-ending foreshortened distal colon: a new variant of persistent cloaca. BMJ Case Rep 2021; 14:e236364. [PMID: 33664021 PMCID: PMC7934755 DOI: 10.1136/bcr-2020-236364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 11/03/2022] Open
Abstract
Persistent cloaca is a rare and severe variety of anorectal malformation, which is more common in females and includes a spectrum of abnormalities. The urinary tract, genital tract and rectum open into a common channel, which exteriorises as a single perineal opening. We are reporting a patient with a novel variation in the classical anatomy of the cloaca. The child has a short blind-ending colon with a cecovesical fistula associated with mullerian agenesis and lipomyelomeningocoele. The child is being managed in a stepwise approach and she has completed the anal reconstruction. Here, we discuss this novel variation in anatomy and challenges in its management.
Collapse
Affiliation(s)
- Rahul Saxena
- Pediatric Surgery, All India Institute of Medical Sciences Jodphur, Jodhpur, India
| | - Manish Pathak
- Pediatric Surgery, All India Institute of Medical Sciences Jodphur, Jodhpur, India
| | - Arvind Sinha
- Pediatric Surgery, All India Institute of Medical Sciences Jodphur, Jodhpur, India
| | | |
Collapse
|
13
|
The use of a Meckel's diverticulum for a neo-vagina in a patient with cloacal anomaly. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
14
|
Treatment guidelines for persistent cloaca, cloacal exstrophy, and Mayer–Rokitansky–Küster–Häuser syndrome for the appropriate transitional care of patients. Surg Today 2019; 49:985-1002. [DOI: 10.1007/s00595-019-01810-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/26/2019] [Indexed: 11/30/2022]
|
15
|
Vilanova-Sanchez A, McCracken K, Halleran DR, Wood RJ, Reck-Burneo CA, Levitt MA, Hewitt G. Obstetrical Outcomes in Adult Patients Born with Complex Anorectal Malformations and Cloacal Anomalies: A Literature Review. J Pediatr Adolesc Gynecol 2019; 32:7-14. [PMID: 30367985 DOI: 10.1016/j.jpag.2018.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 12/22/2022]
Abstract
Patients born with complex anorectal malformations often have associated Müllerian anomalies, which might affect fertility and obstetrical outcomes. Other vertebral-anorectal-tracheoesophageal-renal-limb associations, such as renal or cardiac anomalies, could also affect pregnancy intention, fertility rates, and recommendations about mode of delivery or obstetrical outcomes. Associated conditions present at birth, like hydrocolpos, could also potentially affect fertility. Depending on the complexity of the anomaly, primary reconstruction might include vaginoplasty, vaginal interposition, perineal body reconstruction, and extensive pelvic dissection. After the initial reconstruction, patients might have multiple additional surgeries for stoma reversal, bladder augmentation, and creation of conduits, all with potential for pelvic adhesions. Pregnancy intention, fertility rates, mode of delivery, and obstetrical outcomes data are limited in this patient population, making it challenging to counsel patients and their families. We sought to evaluate all available literature in an attempt to better counsel families. A PubMed literature search was undertaken to review this topic. Search terms of "cloaca," "anorectal malformation," "pregnancy," "cloacal exstrophy," "vaginal delivery," and "cesarean section" were used and citation lists from all identified articles were checked to ensure that all possible articles were included in the review. We also outline comorbidities from the fetal period to adulthood that might affect reproductive health. Of the articles on anorectal and cloacal anomalies, 13 reports were identified that covered obstetrical outcomes. They were in patients with previous anorectal malformation, cloaca, and cloacal exstrophy repair. Twenty-four pregnancies were reported in 16 patients. Two ectopic pregnancies, 5 spontaneous miscarriages, 1 triplet pregnancy, and 16 singleton pregnancies were reported with a total of 19 live births. Regarding the method of conception, 15/18 pregnancies occurred spontaneously and 3/18 were via assisted reproductive technology with in vitro fertilization. There were 19 live births, of which at least 8 were preterm. Müllerian anatomy was reported in 8 of 13 articles. Only 2 patients underwent vaginal delivery (1 patient with repaired cloaca malformation had an operative vaginal delivery and 1 patient with repaired imperforate anus with rectovaginal fistula had a normal spontaneous vaginal delivery). The remaining patients all underwent a cesarean section. There were no reported cases of maternal mortality, and maternal morbidity was limited to recurrent urinary tract infections and worsening chronic kidney disease. There is a paucity of information regarding obstetrical outcomes in adult anorectal and cloaca patients. However, patients with previous cloacal repairs have achieved pregnancy spontaneously, as well as with in vitro fertilization. Patients with repaired cloacal malformations are at increased risk of preterm birth and cesarean delivery. Most patients with cloacal anomalies have an associated Müllerian anomaly and therefore have an increased risk of preterm labor. From our review we conclude that contraception should be offered to patients not desiring pregnancy, and cesarean section is likely the preferred mode of delivery. On the basis of this review, we recommend proactive data collection of all such patients to document outcomes and collaboration among providers and between centers devoted to this complex patient population.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Geri Hewitt
- Nationwide Children's Hospital, Columbus, Ohio
| |
Collapse
|
16
|
Compromised vitality of spermatozoa after contact with colonic mucosa in mice: implications for fertility in colon vaginoplasty patients. Pediatr Surg Int 2019; 35:71-75. [PMID: 30374634 DOI: 10.1007/s00383-018-4377-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 02/06/2023]
Abstract
AIM OF THE STUDY Colon vaginoplasty (CV) is often performed for cloacal malformation (CM). We used mice to study the vitality of spermatozoa after contact with colonic mucosa as a factor contributing to infertility. METHODS Spermatozoa isolated from the epididymides of C57BL/6J male mice (n = 23) were syringed directly into the vaginas (Vag-group) or colons (Colo-group) of female mice (n = 45). Vitality was determined by assessing motility using computer-assisted sperm analysis, viability by staining with SYBR-14 and propidium iodide, and fertility by in vitro fertilization, prior to deposition, and at 5, 10, 30, and 60 min after deposition. MAIN RESULTS Motility was significantly decreased in Colo only at 10 and 60 min. Viability of Colo spermatozoa was significant at all assessment times, except at 10 min. Normal fertilization was observed with all Vag spermatozoa, but with Colo, there was arrest of embryo development with spermatozoa collected at 5 and 10 min, and no fertilization with spermatozoa collected at 30 and 60 min. CONCLUSIONS The vitality of spermatozoa is compromised by contact with colonic mucosa which could contribute to infertility in CM after CV, because their ovaries and fallopian tubes are considered to be normal.
Collapse
|
17
|
Pradhan S, Vilanova-Sanchez A, McCracken KA, Reck CA, Halleran DR, Wood RJ, Levitt M, Hewitt GD. The Mullerian Black Box: Predicting and defining Mullerian anatomy in patients with cloacal abnormalities and the need for longitudinal assessment. J Pediatr Surg 2018; 53:2164-2169. [PMID: 29941357 DOI: 10.1016/j.jpedsurg.2018.05.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/28/2018] [Accepted: 05/15/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Most patients with a cloacal malformation have a Mullerian anomaly. We sought to examine our patients with a cloacal malformation to determine the proportion of them we felt we knew their Mullerian anatomy and which proportion we felt would most benefit from longitudinal assessment to define their anatomy, reproductive potential, and risk of outflow tract obstruction after puberty. We also compared the preoperative assessment of reproductive anatomy (pelvic ultrasound, MRI, cloacagram, and vaginoscopy) and intra-operative abdominal findings (at the time of primary cloacal reconstruction or subsequent abdominal procedures) to see how these correlated with and which preoperative assessment tool was most predictive of intraoperative anatomy. We also sought to confirm what we expected to be a lack of ovarian pathology. METHODS A single site retrospective chart review was performed on all patients with a cloacal anomaly seen between May 2014 and September 2017. Preoperative assessment (pelvic ultrasound, MRI, cloaca gram, and vaginoscopy) and operative reports (both primary reconstruction and later abdominal procedures) were reviewed to ascertain Mullerian and ovarian anatomy. RESULTS 30 of 36 (83%) of patients had defined Mullerian anatomy after preoperative assessment (pelvic ultrasound, MRI, cloacagram, and vaginoscopy) with or without the addition intraoperative assessment of Mullerian structures obtained during laparoscopy or laparotomy. 19/30 (63%) had duplication of their Mullerian structures. 25/36 (69%) had intraoperative assessment of Mullerian anatomy during laparoscopy or laparotomy. In this group, preoperative assessment with pelvic ultrasound correlated in 4/8 patients (50%), MRI correlated in 3/4 patients (75%), cloacagram in 10/15 patients (67%), and vaginoscopy in 23/25 patients (92%). 14/36 (39%) patients were found to require longitudinal assessment to define anatomy, reproductive potential or risk of outflow tract obstruction after puberty. Patients with ovarian findings described at the time of laparoscopy or laparotomy had no evidence of ovarian pathology. CONCLUSIONS The majority of patients with cloaca in our series (83%) had their Mullerian anatomy defined by either preoperative assessment and/or findings at the time of laparoscopy or laparotomy. Duplication of the vagina and uterus was the most commonly described Mullerian anatomy (63%) in our series. Vaginoscopy appears to be superior to pelvic ultrasound, MRI, and cloacagram in predicting Mullerian anatomy. Fourteen of our 36 (39%) patients will require longitudinal assessment follow for reproductive potential and/or risk of outflow tract obstruction after puberty as their Mullerian anatomy is not known. There was no evidence of ovarian pathology in any cloaca patient. While we felt as though we could define Mullerian anatomy in most of our patients, any opportunity for intraoperative assessment of Mullerian anatomy should be utilized and therefore teams who are involved in the management of these patients must have a systematic and collaborative method established to ensure that Mullerian structures are thoroughly evaluated intra-operatively and documented in a standardized fashion. TYPE OF STUDY Retrospective Chart review. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Shashwati Pradhan
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, 395 W 12th Ave, Columbus, OH 43210.
| | - Alejandra Vilanova-Sanchez
- Pediatric Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Katherine A McCracken
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, 395 W 12th Ave, Columbus, OH 43210; Pediatric and Adolescent Gynecology, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Carlos A Reck
- Pediatric Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Devin R Halleran
- Pediatric Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Richard J Wood
- Pediatric Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Marc Levitt
- Pediatric Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
| | - Geri D Hewitt
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, 395 W 12th Ave, Columbus, OH 43210; Pediatric and Adolescent Gynecology, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA.
| |
Collapse
|
18
|
Kittur DH, Vora RM. Persistent Cloaca: A Long-term Follow-up Study. J Indian Assoc Pediatr Surg 2017; 22:126-127. [PMID: 28413311 PMCID: PMC5379873 DOI: 10.4103/0971-9261.202685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Dinesh H Kittur
- Ankur Paed Surgical Clinic, Rajarampuri, Kolhapur, Maharashtra, India
| | - Ravindra M Vora
- S J K C Trust's Paediatric Surgery Centre and Postgraduate Institute, Sangli, Maharashtra, India
| |
Collapse
|
19
|
Higuchi T, Holmdahl G, Kaefer M, Koyle M, Wood H, Woodhouse C, Wood D. International Consultation on Urological Diseases: Congenital Anomalies of the Genitalia in Adolescence. Urology 2016; 94:288-310. [DOI: 10.1016/j.urology.2016.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
20
|
Fertility and sexual dysfunction issues in adults with genitourinary congenital anomalies. Curr Opin Urol 2016; 26:357-62. [PMID: 27139192 DOI: 10.1097/mou.0000000000000295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW As growing numbers of adolescents with a history of congenital genitourinary anomalies successfully enter adulthood, their spectrum of urologic concerns broadens to include sexual function and reproduction. RECENT FINDINGS In hypospadias repair, preoperative testosterone was found to reduce rates of postoperative complications of urethrocutaneous fistula formation and meatal stenosis. Following hypospadias correction, dissatisfaction with surgical outcomes has been observed to correlate with psychological outcomes, rather than objective measurements such as location of meatus degree of curvature. In women with a congenital absence of a vagina, sigmoid vaginoplasty and dilation yield similar sexual outcomes, however, vaginoplasty was associated with a 20% rate of reoperation. Ilioinguinal-to-dorsal neurorrhaphy for restoration of penile sensation in myelomeningocele has shown success in a small pilot study. Both sexual activity and paternity rates are higher in women, compared with men who are born with bladder exstrophy. SUMMARY The extent and complexity of issues related to sexual function and fertility in the population of patients with a history of genitourinary malformation requires a thoughtful approach to timely surgical management and consistent care through their transition from childhood to adulthood.
Collapse
|
21
|
Abstract
Children with anorectal malformations (ARM) constitute a significant group within a pediatric surgery practice. It is important with female cases of anorectal malformations to consider the association of gynecologic anomalies, especially at the time of the definitive repair. However, it is critical to consider the association of such gynecologic anomalies when caring for patients with a cloacal anomaly. If not recognized, an opportunity to diagnose and treat such anomalies may be missed with the possibility of negative implications for future reproductive capacity. With the knowledge of the associated anomalies and long-term sequelae, surgeons can provide better care for girls and important counseling for parents. Knowledge of reproductive related issues in females with cloaca allows the pediatric surgeon an opportunity both, to provide optimal surgical management in infancy, childhood, and into young adulthood and to collaborate medically and surgically with an experienced gynecologist in patients with more complex anatomic variations. Appropriate counseling for patients and families about potential reproductive concerns that may develop many years after the definitive surgical repair allows preparation and planning to preserve future fertility.
Collapse
Affiliation(s)
- Lesley Breech
- University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 2026, Cincinnati, Ohio 45229.
| |
Collapse
|
22
|
Rintala RJ. Congenital cloaca: Long-term follow-up results with emphasis on outcomes beyond childhood. Semin Pediatr Surg 2016; 25:112-6. [PMID: 26969236 DOI: 10.1053/j.sempedsurg.2015.11.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Persistent cloaca remains a challenge for pediatric surgeons and urologists. Reconstructive surgery of cloacal malformations aims to repair the anorectum, urinary tract, and genital organs, and achieve fecal and urinary continence as well as functional genital tract capable for sexual activity and pregnancy. Unfortunately, even in most experienced hands these goals are not always accomplished. The endpoint of the functional development of bowel, urinary, and genital functions is the completion of patient's growth and sexual maturity. It is unlikely that there will be any significant functional improvement beyond these time points. About half of the patients with cloaca attain fecal and urinary continence after their growth period. The remaining half stay clean or dry by adjunctive measures such as bowel management by enemas or ACE channel, and continent urinary diversion or intermittent catheterization. Problems related to genital organs such as obstructed menstruations, amenorrhea, and introitus stenosis are common and often require secondary surgery. Encouragingly, most adolescent and adult patients are capable of sexual life despite often complex vaginal primary and secondary reconstructions. Also, cloacal malformation does not preclude pregnancies, although they still are quite rare. Pregnant patients with cloaca require special care and follow-up to guarantee uncomplicated pregnancy and preservation of anorectal and urinary functions. Cesarean section is recommended for cloaca patients. The self-reported quality of life of cloaca patients appears to be comparable to that of female patients with less complex anorectal malformations.
Collapse
Affiliation(s)
- Risto J Rintala
- Department of Pediatric Surgery Children's Hospital, Helsinki University Central Hospital Stenbackinkatu 11 Helsinki, PO Box 261, FIN-00029 HUS, Helsinki, Finland.
| |
Collapse
|
23
|
|
24
|
Couchman A, Creighton SM, Wood D. Adolescent and Adult Outcomes in Women Following Childhood Vaginal Reconstruction for Cloacal Anomaly. J Urol 2015; 193:1819-22. [DOI: 10.1016/j.juro.2014.10.112] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Ashani Couchman
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Sarah M. Creighton
- University College London Institute of Women's Health, London, United Kingdom
| | - Dan Wood
- University College London Hospitals, London, United Kingdom
| |
Collapse
|
25
|
Fernando MA, Creighton SM, Wood D. The long-term management and outcomes of cloacal anomalies. Pediatr Nephrol 2015; 30:759-65. [PMID: 25217327 PMCID: PMC4372671 DOI: 10.1007/s00467-014-2875-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 05/03/2014] [Accepted: 06/02/2014] [Indexed: 12/03/2022]
Abstract
Cloacal anomalies occur when failure of the urogenital septum to separate the cloacal membrane results in the urethra, vagina, rectum and anus opening into a single common channel. The reported incidence is 1:50,000 live births. Short-term paediatric outcomes of surgery are well reported and survival into adulthood is now usual, but long-term outcome data are less comprehensive. Chronic renal failure is reported to occur in 50 % of patients with cloacal anomalies, and 26-72 % (dependant on the length of the common channel) of patients experience urinary incontinence in adult life. Defaecation is normal in 53 % of patients, with some managed by methods other than surgery, including medication, washouts, stoma and antegrade continent enema. Gynaecological anomalies are common and can necessitate reconstructive surgery at adolescence for menstrual obstruction. No data are currently available on sexual function and little on the quality of life. Pregnancy is extremely rare and highly risky. Patient care should be provided by a multidisciplinary team with experience in managing these and other related complex congenital malformations. However, there is an urgent need for a well-planned, collaborative multicentre prospective study on the urological, gastrointestinal and gynaecological aspects of this rare group of complex conditions.
Collapse
Affiliation(s)
- M. Ashani Fernando
- Department of Urology, University College London Hospitals, 250 Euston Road, London, NW1 2PG UK
| | - Sarah M. Creighton
- Department of Women’s Health, University College London Hospitals, 250 Euston Road, London, NW1 2PG UK
| | - Dan Wood
- Department of Urology, University College London Hospitals, 250 Euston Road, London, NW1 2PG UK
| |
Collapse
|
26
|
Versteegh HP, Sloots CEJ, Wolffenbuttel KP, de Jong JR, Sleeboom C, Feitz WF, van Heurn LWE, van der Zee DC, Wijnen RMH, de Blaauw I. Urogenital function after cloacal reconstruction, two techniques evaluated. J Pediatr Urol 2014; 10:1160-4. [PMID: 24957462 DOI: 10.1016/j.jpurol.2014.04.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 04/21/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Current surgical techniques for cloacal reconstruction are posterior sagittal anorecto vagino urethroplasty (PSARVUP) and posterior sagittal anorectoplasty (PSARP) with total urogenital mobilization (TUM). The aim of this study was to explore the results of reconstructive cloaca surgery in the Netherlands and evaluate urogenital function after PSARVUP and TUM. PATIENTS AND METHODS Medical records from five pediatric surgical departments in the Netherlands were studied for patients with cloacal malformations treated between 1985 and 2009. Forty-two patients were eligible, and patients with short common channels were categorized into PSARVUP and TUM groups. Groups were compared using Fisher's exact test. RESULTS Median age at time of surgery was 9 months (range 1-121). In 24 patients (57%) a PSARVUP was done, in 18 patients (43%) TUM. Median follow-up was 142 months (range 15-289). At follow-up spontaneous voiding was seen in 29 patients (69%). Clean intermittent catheterization (CIC) was needed in 14 patients (33%); a urinary diversion was created in 10 patients (24%). In total 32 patients (76%) were dry with no involuntary loss of urine per urethra. Recurrent urinary tract infections were seen in 23 patients (55%). When comparing PSARVUP and TUM groups in our series of patients with short common channels, there were no differences in urological outcome. Normal menstruation was present in 11 of the 20 patients who reached puberty (55%). CONCLUSION Urogenital functional outcome after reconstructive surgery for cloacal malformations was similar in PSARVUP and TUM groups in patients with short common channels. A thorough urological follow-up is needed to establish the long-term bladder function and urinary incontinence results to prevent long-term risks of recurrent UTI. Albeit without differences between PSARVUP and TUM groups, 45% of the patients present with abnormal or absent menstruations. Gynecological follow-up is mandatory in all patients with cloacal malformations 6 months after the first sign of puberty.
Collapse
Affiliation(s)
- Hendt P Versteegh
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Cornelius E J Sloots
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Katja P Wolffenbuttel
- Dept. of Pediatric Urology, Erasmus MC-Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Justin R de Jong
- Pediatric Surgical Center Amsterdam, Emma Children's Hospital AMC & VU University Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
| | - Christien Sleeboom
- Pediatric Surgical Center Amsterdam, Emma Children's Hospital AMC & VU University Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
| | - Wout F Feitz
- Dept. of Pediatric Urology, Radboud University Medical Center - Amalia Children's Hospital, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - L W Ernest van Heurn
- Dept. of Pediatric Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - David C van der Zee
- Dept. of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands.
| | - Rene M H Wijnen
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | - Ivo de Blaauw
- Dept. of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands; Dept. of Surgery - Pediatric Surgery, Radboud University Medical Center - Amalia Children's Hospital, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| |
Collapse
|
27
|
The Great Divide: Understanding Cloacal Septation, Malformation, and Implications for Surgeons. Pediatr Surg Int 2014; 30:1089-95. [PMID: 25217828 PMCID: PMC4302733 DOI: 10.1007/s00383-014-3593-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2014] [Indexed: 12/28/2022]
Abstract
The anorectal and urogenital systems arise from a common embryonic structure termed cloaca. Subsequent development leads to the division/septation of the cloaca into the urethra, urinary bladder, vagina, anal canal, and rectum. Defective cloacal development and the resulting anorectal and urogenital malformations are some of the most severe congenital anomalies encountered in children. In the most severe form in females, the rectum, vagina, and urethra fail to develop separately and drain via a single common channel known as a cloaca into the perineum. In this review, we summarize our current knowledge of embryonic cloaca development and malformation, and compare them to what has already been described in the literature. We describe the use of mouse models of cloaca malformation to understand which signaling pathways and cellular mechanisms are involved in the process of normal cloaca development. We also discuss the embryological correlation of the epithelial and stromal histology found in step sections of the common channel in 14 human cloaca malformations. Finally, we highlight the significance of these findings, compare them to prior studies, and discuss their implications for the pediatric surgeons. Understanding and identifying the molecular basis for cloaca malformation could provide foundation for tissue engineering efforts that in the future would reflect better surgical reconstruction and improved quality of life for patients.
Collapse
|
28
|
Experiences of surgical continence management approaches for cloacal anomalies: a qualitative analysis based on 6 women. J Pediatr Adolesc Gynecol 2014; 27:266-70. [PMID: 24841521 DOI: 10.1016/j.jpag.2013.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 11/13/2013] [Accepted: 11/14/2013] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE The aim of this qualitative study was to gain insight into health care experiences of young women diagnosed with cloacal anomalies, with a special focus on continence management. DESIGN Qualitative analysis of one-to-one interviews. SETTING A tertiary center for congenital anomalies of the urogenital tract in London. PARTICIPANTS Six women aged 16 to 24 with cloacal anomalies. INTERVENTIONS Tape-recorded one-to-one semi-stuctured interviews with a skilled interviewer. MAIN OUTCOME MEASURE(S) The taped interviews were transcribed and analyzed verbatim using interpretative phenomenological analysis according to the research question. Organizing themes across all of the accounts were identified. RESULTS Two organizing themes concerning our research interests are summarized. The first theme Personal Agency in the Hands of Experts focuses on the interviewees' appreciation of their life-saving surgical care and their involvement in treatment decisions. The second theme Compromises and Trade-Offs focuses on what it was like to live with the more traditional versus the more advanced continence methods. Reliability emerged as a key priority in terms of continence treatment outcome. Gratitude may have interfered with the women's honest communications during treatment decision and evaluation consultations. CONCLUSIONS A more developed approach to communication about the complex interventions proposed, founded on a nuanced understanding of users perspectives, can enhance informed decision making about continence management approaches. Despite these specific gaps, the interviewees were appreciative of their care and optimistic about life.
Collapse
|
29
|
Tennant PWG, Glinianaia SV, Wellesley D, Draper ES, Kurinczuk JJ, Tonks AM, Tucker DF, Wreyford B, Rankin J. Epidemiology of partial urorectal septum malformation sequence (or 'persistent cloaca'): a population-based study in seven regions of England and Wales, 1985-2010. Arch Dis Child Fetal Neonatal Ed 2014; 99:F413-8. [PMID: 25115921 DOI: 10.1136/archdischild-2014-306027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Partial urorectal septum malformation (pURSM) sequence (or 'persistent cloaca') is a rare congenital anomaly characterised by a joining of the urethral, anal, and genital openings into a single common channel. This study describes the epidemiology of pURSM sequence in England and Wales including prevalence, additional anomalies, and pregnancy outcomes. METHODS All cases of pURSM sequence prospectively notified to seven congenital anomaly registers in England and Wales during 1985-2010, whether delivered as live births, spontaneous fetal deaths (≥20 weeks' gestation), or elective terminations of pregnancy for fetal anomaly (TOPFA, any gestation), formed this population-based cohort. The risks of spontaneous fetal and infant death were examined by Kaplan-Meier analysis. Differences in prevalence over time, and between regions, were examined by multilevel Poisson regression. RESULTS 117 cases were recorded among 4,251,241 total births. Six (5%) pregnancies resulted in spontaneous fetal deaths, 53 (45%) in TOPFA, and 58 (50%) in live births. The prevalence was 2.8 (95% CI 2.3 to 3.4) per 100,000 total births, increasing significantly over time (p=0.002) and differing significantly between regions (p=0.005). 77 cases (66%) had at least one additional major congenital anomaly outside the perineum, including 67 (57%) renal, 29 (25%) musculoskeletal, 26 (23%) digestive system, and 24 (21%) cardiovascular anomalies. The risks of spontaneous fetal and infant death were estimated as 8.9% (95% CI 4.1 to 18.8) and 26.3% (95% CI 15.1 to 43.4) respectively. CONCLUSIONS This is the largest study of the epidemiology of pURSM sequence. The information will be valuable for families and health professionals whenever a case of pURSM sequence is diagnosed.
Collapse
Affiliation(s)
- Peter W G Tennant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Diana Wellesley
- Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, UK
| | | | - Jenny J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ann M Tonks
- West Midlands Congenital Anomaly Register, Public Health England, Birmingham, UK
| | - David F Tucker
- Congenital Anomaly Register and Information Service for Wales, Public Health Wales, Swansea, UK
| | - Ben Wreyford
- School of Clinical Sciences, Bristol University, Bristol, UK
| | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK Regional Maternity Survey Office, Public Health England, Newcastle upon Tyne, UK
| |
Collapse
|
30
|
Huibregtse ECP, Draaisma JMT, Hofmeester MJ, Kluivers K, van Rooij IALM, de Blaauw I. The influence of anorectal malformations on fertility: a systematic review. Pediatr Surg Int 2014; 30:773-81. [PMID: 24969818 DOI: 10.1007/s00383-014-3535-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE This systematic review aims to give an overview of available evidence concerning the influence of anorectal malformations (ARM) on fertility. METHODS We conducted a search in PubMed, EMBASE and Cochrane Library conformed to the PRISMA standards. All studies reporting on fertility and ARM were included. RESULTS 2,905 studies were identified. Based on title, abstract and full text, nine articles on 429 patients remained to answer the research question. Childbirth rate was the only reported outcome parameter to describe fertility. An overall childbirth rate of 27 % (range 0-57 %) was found. Mean age at time of study ranged from 23 to 35 years. There was no statistical significant difference in childbirth rate between female and male patients, based on seven studies (p = 0.45). Patients with a more complex type of ARM (imperforated anus without fistula, rectourethral bulbar and prostatic fistulas, rectobladderneck fistulas and cloacal malformations) had a lower childbirth rate compared to healthy controls, whereas in patients with a less complex ARM (rectoperineal or rectovestibular fistula) the childbirth rate was similar to healthy controls. Patients with a more complex type of ARM had a significant lower childbirth rate than patients with a less complex type of ARM (18 vs 47 %, respectively) (p = 0.0001). When further dividing these patients by gender, this difference was only seen in female patients (p = 0.04). CONCLUSION In patients with a more complex type of ARM a lower childbirth rate was found compared to healthy controls and patients with a less complex type of ARM. The latter was only seen in female patients. However, conclusions concerning fertility in ARM patients have to be taken with caution due to limited quality of the studies. Further investigation is recommended.
Collapse
Affiliation(s)
- E C P Huibregtse
- Department of Pediatric Surgery, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | | | | | | | | | | |
Collapse
|
31
|
Song SH, Kim A, Lim B, Park S, Kim KS. Endoscopic surgery as an adjuvant treatment modality before or after definitive correction of cloacal anomalies. J Pediatr Urol 2014; 10:336-43. [PMID: 24456819 DOI: 10.1016/j.jpurol.2013.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 09/29/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of endoscopic surgery before or after definitive correction in patients with a persistent cloaca. MATERIALS AND METHODS The medical records of 16 patients diagnosed with persistent urogenital sinus at our institution were retrospectively reviewed. Of these 16 patients, five underwent endoscopic surgery, such as visual internal urethrotomy or transurethral incision by a single surgeon at the time of or after colostomy formation or corrective surgery. RESULTS All patients underwent colostomy 1-2 days after birth. Three patients were treated by endoscopic procedures before corrective surgery owing to voiding difficulty, urinary tract infection, or hydrocolpos, at a median age of 1 month. Another two patients underwent endoscopic surgery after definitive correction of the cloaca owing to urethral stricture or urinary incontinence. After endoscopic surgery, all patients voided well without residual urine or were catheterised easily without incontinence. Endoscopic modality played a substantial role in managing complications or resolving the anatomical barrier to decompress the genitourinary tract in patients with a common urogenital sinus length of <3 cm. CONCLUSIONS Endoscopic surgery for a cloacal anomaly is a minimally invasive adjuvant technique for bladder neck obstruction, urethral stricture, and hydrocolpos with a thickened vaginal septum.
Collapse
Affiliation(s)
- Sang Hoon Song
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Centre, Pungnap-Dong 388-1, Songpa-Gu, Seoul, Republic of Korea.
| | - Aram Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Centre, Pungnap-Dong 388-1, Songpa-Gu, Seoul, Republic of Korea.
| | - Bumjin Lim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Centre, Pungnap-Dong 388-1, Songpa-Gu, Seoul, Republic of Korea.
| | - Sungchan Park
- Department of Urology, Ulsan University Hospital, Ulsan, Republic of Korea.
| | - Kun Suk Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Asan Medical Centre, Pungnap-Dong 388-1, Songpa-Gu, Seoul, Republic of Korea.
| |
Collapse
|
32
|
Versteegh HP, van Rooij IALM, Levitt MA, Sloots CEJ, Wijnen RMH, de Blaauw I. Long-term follow-up of functional outcome in patients with a cloacal malformation: a systematic review. J Pediatr Surg 2013; 48:2343-50. [PMID: 24210210 DOI: 10.1016/j.jpedsurg.2013.08.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 07/05/2013] [Accepted: 08/16/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Reconstructive surgery is performed in patients with cloacal malformations to achieve anorectal, urological, and gynecological function. The aim of this study was to evaluate the functional outcome of cloacal malformation repair as reported in literature. METHODS A systematic literature search was conducted according to PRISMA guidelines using PubMed, EMbase, and Web-of-Science. Records were assessed for the reporting of functional outcomes, which was divided into anorectal, urological, or gynecological function. Studies were used in qualitative (Rangel score) and quantitative syntheses. RESULTS Twelve publications were eligible for inclusion. Voluntary bowel movements were reported in 108 of 188 (57%), soiling in 146 of 205 (71%), and constipation in 31 of 61 patients (51%). Spontaneous voiding was reported for 138 of 299 patients (46%). 141 of 332 patients (42%) used intermittent catheterization, and 53 of 237 patients (22%) had a urinary diversion. Normal menstruations were reported for 25 of 71 patients (35%). Centers with limited experience reported similar outcome compared to centers with more experience (≥1 patients/year). CONCLUSION In this review we present functional outcome of the largest pooled cohort of patients with cloacal malformations as reported from 1993 to 2012. Functional disturbances are frequently encountered in anorectal, urological, as well as gynecological systems. Reporting of functional outcome in these patients should improve to increase knowledge about long-term results in patients with this rare malformation and to reach higher study quality. Especially, sacral and spinal anomalies should always be reported given their impact on functional outcome. Specialized care centers may be of great importance for patients with rare and complex conditions.
Collapse
Affiliation(s)
- Hendt P Versteegh
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
33
|
Rasouly HM, Lu W. Lower urinary tract development and disease. WILEY INTERDISCIPLINARY REVIEWS. SYSTEMS BIOLOGY AND MEDICINE 2013; 5:307-42. [PMID: 23408557 PMCID: PMC3627353 DOI: 10.1002/wsbm.1212] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Congenital anomalies of the lower urinary tract (CALUT) are a family of birth defects of the ureter, the bladder, and the urethra. CALUT includes ureteral anomaliesc such as congenital abnormalities of the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ), and birth defects of the bladder and the urethra such as bladder-exstrophy-epispadias complex (BEEC), prune belly syndrome (PBS), and posterior urethral valves (PUVs). CALUT is one of the most common birth defects and is often associated with antenatal hydronephrosis, vesicoureteral reflux (VUR), urinary tract obstruction, urinary tract infections (UTI), chronic kidney disease, and renal failure in children. Here, we discuss the current genetic and molecular knowledge about lower urinary tract development and genetic basis of CALUT in both human and mouse models. We provide an overview of the developmental processes leading to the formation of the ureter, the bladder, and the urethra, and different genes and signaling pathways controlling these developmental processes. Human genetic disorders that affect the ureter, the bladder and the urethra and associated gene mutations are also presented. As we are entering the postgenomic era of personalized medicine, information in this article may provide useful interpretation for the genetic and genomic test results collected from patients with lower urinary tract birth defects. With evidence-based interpretations, clinicians may provide more effective personalized therapies to patients and genetic counseling for their families.
Collapse
Affiliation(s)
- Hila Milo Rasouly
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA 02118, USA
| | - Weining Lu
- Renal Section, Department of Medicine, Boston University Medical Center, Boston, MA 02118, USA
| |
Collapse
|
34
|
Schmidt D, Winter S, Jenetzky E, Zwink N, Schmiedeke E, Maerzheuser S. Sexual function in adults with anorectal malformation: psychosocial adaptation. German Network for Congenital Uro-REctal Malformations (CURE-Net). Pediatr Surg Int 2012; 28:789-92. [PMID: 22791012 DOI: 10.1007/s00383-012-3119-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of the German Network for Congenital Uro-REctal Malformations (CURE-Net) is to collect data of affected patients with anorectal malformation (ARM) to investigate molecular causes, clinical implications and psychosocial outcome. The current issue was to examine sexual function and to explore psychosocial adaptation in adults with ARM. METHODS This qualitative study using narrative inquiry is part of a larger multi-center study of clinical queries and quality of life in patients with ARM. The guided interview focused on analysis of sexual function. RESULTS 55 adult patients with ARM (23 females, 32 males, median age 23 years, range from 18 to 56 years) were investigated via standardized case-report forms comprising interview, analysis of medical data and personal questionnaires. In the female patients, 8 (35 %) of them lived alone and 15 (65 %) had sexual intercourse. In the male patients, the majority of 20 (69 %) patients lived alone and 13 (45 %) had sexual intercourse. 6 of the females got pregnant, 5 got 2 or more children. 3 of the men induced 2 or more pregnancies and fathered children. CONCLUSION Besides reconstructing the ARM, another main goal is the preservation of sexual function. According to our data, there seems to be a close relationship between psychosocial development and sexual activity.
Collapse
Affiliation(s)
- Dominik Schmidt
- Department of Pediatric Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | | | | |
Collapse
|
35
|
Nakhal RS, Wood D, Creighton SM. The role of examination under anesthesia (EUA) and vaginoscopy in pediatric and adolescent gynecology: a retrospective review. J Pediatr Adolesc Gynecol 2012; 25:64-6. [PMID: 22051793 DOI: 10.1016/j.jpag.2011.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Revised: 08/22/2011] [Accepted: 08/22/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Examination under anesthesia (EUA) with diagnostic vaginoscopy is an invaluable method in the lower genital tract assessment of pediatric and adolescent females. The literature on this topic remains scarce. METHODS This is a retrospective medical notes review of all patients who underwent EUA with or without vaginoscopy over the past 5 years at a pediatric and adolescent gynecology unit specializing in disorders of sex development (DSD). RESULTS From 2005 to 2010, 83 patients underwent 92 procedures. All procedures were performed under general anesthesia, and a 3-mm pediatric cystoscope was used for vaginoscopy. Of the 92 cases, 33 (36%) were EUA alone and 59 (64%) consisted of a combined EUA and vaginoscopy. The mean age was 13.3 ± 3.7 years. The most common indications included assessment for reconstructive surgery (33.7%), vaginal stenosis (21.7%), vaginal discharge (19.6%), vaginal bleeding (16.3%), and pelvic pain (8.7%). Most (61%) of those presenting for assessment for reconstructive surgery had a DSD and history of surgical correction in early childhood. In 88 cases (96%), the evaluation was satisfactory and a diagnosis was reached or normality confirmed. Four cases (4%) required further investigation. No significant intraoperative or postoperative complications were encountered. Of the 92 cases, 15 (16%) required a further minor procedure, which was performed at the time of the EUA/vaginoscopy. Another 33 (36%) required further major surgery, which was performed at a later date. CONCLUSION EUA/vaginoscopy is a safe and highly useful method in the assessment of the lower genital tract in pediatric and adolescent patients.
Collapse
Affiliation(s)
- Rola S Nakhal
- Elizabeth Garrett Anderson UCL Institute of Women's Health, London, United Kingdom.
| | | | | |
Collapse
|
36
|
Shrim A, Podymow T, Breech L, Dahan MH. Term Delivery After In Vitro Fertilization in a Patient With Cloacal Malformation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:952-954. [DOI: 10.1016/s1701-2163(16)35021-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
37
|
Rintala RJ, Pakarinen MP. Outcome of anorectal malformations and Hirschsprung's disease beyond childhood. Semin Pediatr Surg 2010; 19:160-7. [PMID: 20307853 DOI: 10.1053/j.sempedsurg.2009.11.021] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Anorectal malformations (ARMs) and Hirschsprung disease (HD) are the most common congenital colorectal defects in the newborn. The outcomes of HD and ARMs have improved significantly because of improved understanding of the pathologic anatomy and physiology of these defects and of the modern surgical techniques. Still, many patients suffer from defective bowel control even as adults. Some of these also have problems with urinary control and sexual functions. The functional problems are more pronounced in patients with ARMs. Compared with healthy people, both patients with ARMs and those with HD have limitations in their quality of life. Inferior quality of life is more common in patients with ARMs. There are very few published data on long-term outcome of adults with ARMs and HD. The effect of aging on the functional outcome and quality of life remains unclear, although some preliminary data suggest that the bowel function and quality of life may deteriorate with aging.
Collapse
Affiliation(s)
- Risto J Rintala
- Section of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, FIN-00029Helsinki, Finland.
| | | |
Collapse
|
38
|
Abstract
Children with anorectal malformations (ARMs) constitute a significant group within a pediatric surgery practice. In females, the most common ARM is an imperforate anus with a rectovestibular fistula, followed by an imperforate anus with a rectoperineal fistula and then cloacal anomalies. Some malformations, such as an imperforate anus with a rectovestibular fistula, may seem straightforward, treated with a posterior sagittal anorectoplasty; however, it is vital to recognize the association with gynecologic anomalies. Girls with the most complex anorectal defect, cloacal malformation, have significant associated urological and gynecologic anomalies, which should be recognized and treated. An opportunity to diagnose and treat such anomalies may be missed in the newborn period or at the definitive surgery, unless the pediatric surgeon is aware of this association. With the knowledge of the associated anomalies and long-term sequelae, surgeons can provide better care for girls and important counseling for parents. Important gynecologic issues to consider may be divided into several categories, such as infancy, puberty, sexual intimacy, and obstetrical concerns. Knowledge of reproductive-related issues in females with ARMs allows the pediatric surgeon and their gynecology colleagues to provide optimal surgical management throughout infancy, childhood, and into young adulthood. Appropriate counseling for patients and families about potential reproductive concerns that may develop many years after the definitive surgical repair allows preparation and planning to preserve future fertility.
Collapse
Affiliation(s)
- Lesley Breech
- Pediatric and Adolescent Gynecology Program, Division of Adolescent Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA.
| |
Collapse
|
39
|
Michala L, Aslam N, Conway GS, Creighton SM. The clandestine uterus: or how the uterus escapes detection prior to puberty. BJOG 2009; 117:212-5. [DOI: 10.1111/j.1471-0528.2009.02413.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
40
|
Abstract
Duplex/color Doppler sonography (US) is the imaging modality of choice for the evaluation of patients with primary amenorrhea. Careful correlation with clinical history, physical examination and laboratory findings significantly narrows the diagnostic possibilities thus allowing for a more precise diagnosis. This article discusses the wide gamut of etiologies of primary amenorrhea, the US appearance of pathologic processes that result in primary amenorrhea, and helps the reader understand when additional higher tech imaging is indicated.
Collapse
|
41
|
Salvi N, Arthur I. A case of successful pregnancy outcome in a patient born with cloacal malformation. J OBSTET GYNAECOL 2009; 28:343-5. [DOI: 10.1080/01443610802047992] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
42
|
Leclair MD, Gundetti M, Kiely EM, Wilcox DT. The Surgical Outcome of Total Urogenital Mobilization for Cloacal Repair. J Urol 2007; 177:1492-5. [PMID: 17382761 DOI: 10.1016/j.juro.2006.11.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Indexed: 11/23/2022]
Abstract
PURPOSE Total urogenital mobilization is deemed to preserve the urogenital sinus blood supply and avoid ischemic complications. We report our experience with this technique for cloacal repair. MATERIALS AND METHODS We retrospectively reviewed all consecutive cases of persistent cloaca managed by total urogenital mobilization via a posterior sagittal approach by a single pediatric urologist between 1998 and 2003. During this period 22 girls (12 with a common channel longer than 3 cm) underwent total urogenital mobilization for cloaca repair (1 redo) at a median age of 10 months (range 2 to 102). A total of 15 procedures (68%) could be completed by a perineal approach only. Four patients with a long common channel required additional maneuvers after mobilization to complete the reconstruction. RESULTS Urethral stenosis was observed in 2 patients after urethral separation from the vagina (1) and common channel retubularization (1). One child with a perineal hemangioma required a redo posterior sagittal anorectoplasty for complete vaginal and anal closure. In addition, 1 case of urethrovaginal fistula was diagnosed on cystovaginoscopy but was asymptomatic, and 1 child with a minor residual common channel underwent urethral revision to allow easier intermittent catheterization. With a median followup of 48 months (range 11 to 162) the latest examination involving endoscopy with anesthesia showed a good result in 17 patients, a tight introitus that might require further surgery in 3 and a minimal residual common channel of 0.5 cm in 2. CONCLUSIONS Total urogenital mobilization is an effective technique for repairing short and long common channels, and a low surgical complication rate can be anticipated.
Collapse
Affiliation(s)
- Marc-David Leclair
- Pediatric Urology and Pediatric Surgery Departments, Great Ormond Street Hospital for Children, London, United Kingdom.
| | | | | | | |
Collapse
|
43
|
Jenkins D, Bitner-Glindzicz M, Thomasson L, Malcolm S, Warne SA, Feather SA, Flanagan SE, Ellard S, Bingham C, Santos L, Henkemeyer M, Zinn A, Baker LA, Wilcox DT, Woolf AS. Mutational analyses of UPIIIA, SHH, EFNB2 and HNF1beta in persistent cloaca and associated kidney malformations. J Pediatr Urol 2007; 3:2-9. [PMID: 17476318 PMCID: PMC1864944 DOI: 10.1016/j.jpurol.2006.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES 'Persistent cloaca' is a severe malformation affecting females in which the urinary, genital and alimentary tracts share a single conduit. Previously, a Uroplakin IIIA (UPIIIA) mutation was reported in one individual with persistent cloaca, and UPIIIA, Sonic Hedgehog (SHH), Ephrin B2 (EFNB2) and Hepatocyte Nuclear Factor 1beta (HNF1beta) are expressed during the normal development of organs that are affected in this condition. HNF1beta mutations have been associated with uterine malformations in humans, and mutations of genes homologous to human SHH or EFNB2 cause persistent cloaca in mice. PATIENTS AND METHODS We sought mutations of coding regions of UPIIIA, SHH, EFNB2 and HNF1beta genes by direct sequencing in a group of 20 patients with persistent cloaca. Most had associated malformations of the upper renal tract and over half had impaired renal excretory function. The majority of patients had congenital anomalies outside the renal/genital tracts and two had the VACTERL association. RESULTS Apart from a previously described index case, we failed to find UPIIIA mutations, and no patient had a SHH, EFNB2 or HNF1beta mutation. CONCLUSION Persistent cloaca is only rarely associated with UPIIIA mutation. Despite the fact that SHH and EFNB2 are appealing candidate genes, based on their expression patterns and mutant mice phenotypes, they were not mutated in these humans with persistent cloaca. Although HNF1beta mutations can perturb paramesonephric duct fusion in humans, HNF1beta was not mutated in persistent cloaca.
Collapse
Affiliation(s)
- Dagan Jenkins
- Nephro-Urology Unit, Institute of Child Health, University College London, 30 Guilford Street, London WCIN IEH, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
Downsizing and refinement of the pediatric endoscope in video-monitoring systems have facilitated genitourinary endoscopy even in small children without any traumatic instrumentation. Indications for endoscopy in children with hematuria or tractable urinary tract infection have been tailored for the rareness of genitourinary malignancy or secondary vesicoureteral reflux (VUR) as a result of infravesical obstruction. Most mechanical outlet obstructions can be relieved endoscopically irrespective of sex and age. Endoscopic decompression by puncture or incision of both intravesical and ectopic ureteroceles can be an initial treatment similar to open surgery for an affected upper moiety. Endoscopy is necessary following urodynamic study to exclude minor infravesical obstruction only in children with unexplained dysfunctional voiding. Genitourinary endoscopy is helpful for structural abnormalities before and at the time of repairing congenital urogenital anomalies. Endoscopic injection therapy of VUR has been established as a less invasive surgical treatment. Pediatric endoscopy will play a greater role in the armamentarium for most pediatric urological diseases through the analysis of visual data and discussion on the indications for endoscopy throughout the world.
Collapse
Affiliation(s)
- Katsuya Nonomura
- Hokkaido University, Graduate School of Medicine and Department of Urology, Renal and Genitourinary Surgery, Sapporo, Japan.
| | | |
Collapse
|
45
|
Abstract
Clinicians caring for newborns with persistent cloaca face significant challenges in the newborn period. Avoiding key pitfalls during this time can have dramatic implications. We reviewed the medical records of 361 patients with cloaca operated on at our institution and analyzed sequelae that resulted from incorrect management in the newborn period. Of 361 patients, 282 underwent primary operations at our institution, and 79 patients were referred to us after a failed repair at other institutions. Pitfalls in management during the newborn period included the following: (1) Failure to recognize and manage hydrocolpos, which occurred in 46 patients. Of these, three patients developed pyocolpos (two progressed to vaginal perforation), and 43 suffered from persistent bilateral hydronephrosis, megaureters, recurrent urinary tract infections, persistent acidosis, or failure to thrive due to undrained hydrocolpos. They underwent unnecessary urinary drainage procedures (nephrostomy, ureterostomy, cystostomy, or vesicostomy) in the newborn period. When the vagina was finally decompressed, all of these symptoms disappeared. (2) Colostomy or vesicostomy problems, which occurred in 50 patients. These included incorrect placement of the colostomy (too distal, which interfered with the pull-through) in 24 and colostomy prolapse in 23. Incompletely diverting loop colostomies led to urinary tract infections in 49 patients. Vesicostomy prolapse occurred in three patients. (3) Clinical misdiagnosis, which occurred in 42 patients. Six were incorrectly diagnosed as "intersex" and 36 as "rectovaginal fistula." In this group only the rectum was repaired, and the patients were left with a urogenital sinus that required reoperation. Proper management of a newborn with cloaca includes drainage of a hydrocolpos, which avoids unnecessary urinary diversions and pyocolpos. Our preferred colostomy is one with separated stomas, adequate distal bowel for the pull-through, and use of a proper technique to avoid prolapse. Correct clinical diagnosis of cloaca avoids problems during the definitive repair.
Collapse
Affiliation(s)
- Marc A Levitt
- North Shore--Long Island Jewish Medical Center, Schneider Children's Hospital, 269-01, 76th Avenue, New Hyde Park, NY 11040, USA.
| | | |
Collapse
|
46
|
Davies MC, Creighton SM, Wilcox DT. Long-term outcomes of anorectal malformations. Pediatr Surg Int 2004; 20:567-72. [PMID: 15309468 DOI: 10.1007/s00383-004-1231-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Accepted: 03/15/2004] [Indexed: 10/26/2022]
Abstract
Anorectal malformations (ARMs) and cloacal anomalies are rare and complex malformations of the lower gastrointestinal and genitourinary tracts. They affect approximately 1 in 3,500 live births. The treatment of these patients has traditionally focused on achieving urinary and faecal continence, with preservation of renal function. With improved surgical techniques and paediatric intensive care facilities, these patients now live relatively normal lives, with a near-normal life expectancy. Comparing results reported by different surgeons is difficult because a wide range of terminology is employed to describe the anomalies encountered. This paper attempts to simplify some of the reported outcomes of bowel function to allow a more direct comparison between groups. Urinary outcomes were not so easily comparable due to the disparity in assessing patient outcomes. Therefore, before a global analysis of all groups can take place, a standardised terminology will be necessary. At present there is a gap in the published literature of comprehensive follow-up in this group of patients, particularly regarding reproductive and sexual functioning. More detailed information on long-term outcomes is needed in these patients to facilitate informed decision-making by the primary physician (usually the paediatric surgeon) and the parents on behalf of their child.
Collapse
Affiliation(s)
- Melissa C Davies
- Academic Department of Obstetrics and Gynaecology, University College London, 86-96 Chenies Mews, London WC1E 6HX, UK.
| | | | | |
Collapse
|